Insurance for International Students

Insurance Policy Details

Fall 2014 - Summer 2015 Policy Details

The information below is a synopsis of the Blue Cross Blue Shield policy information, and is subject to change. To view the most up-to-date information, view the online brochure at Blue Cross Blue Shield.

Unlimited maximum per insured person, per policy year

$500 PPO Network deductible per insured person per policy year; $1,500 for a family

$1000 Non-network deductible per insured person per policy year; $3,000 for a family

$6,250 PPO Network out-of-pocket maximum per insured person per policy year; $12,700 for a family

$12,500 Non-network out-of-pocket maximum per insured person per policy year; $37,500 for a family

If the student uses staff and/or services not listed on the Blue Cross Blue Shield network, the student pays a higher percentage of the bill, 40% of Usual and Customary charges plus 100% or any charges above Usual and Customary prices. It benefits you financially to stay within the assigned network.

3 In Network Urgent Care does NOT cover the following at 100%: Surgery, Physical Medicine, Psychological testing, hearing aids and Dialysis. These are subject to DED 80% payment for PPO Network and 20% payment for Non-network.

Prescription Benefits

There is not a maximum on the prescription benefit. You must purchase the prescription in full from a pharmacy of your choice. Prescription coverage for PPO Network pharmacies are covered at 100% after:

$15 copay for Generic drugs

$30 copay for Preferred Brand drugs

$50 copay for Name Brand drugs

To get the most of out of your prescription benefit, ask your doctor if generic drugs are available. If you need to file a claim for reimbursement through Prime Therapeutics, see the claims page.

Proof of Insurance Card

Blue Cross Blue Shield sends one card per school year to policyholders. In your first semester of coverage you should receive an insurance card 2-4 weeks after Census Day. (Because eligibility for the UT Dallas Student Health Insurance Plan is contingent upon enrollment at UT Dallas, insurance cards cannot be sent until all students are officially registered, which is Census Day.) You may also print a card from the Blue Cross Blue Shield website at that time.

Interim Coverage Letter

Because your student health insurance coverage must be renewed each semester, the dates of your coverage coincide with each respective semester. Should you need to receive medical treatment or fill a prescription between the start date of the current semester’s insurance policy and census day of the current semester, please contact stuhealthinsurance@utdallas.edu or call 972-883-2747 to secure an Interim Coverage Letter. The Interim Coverage Letter will serve as your temporary proof of insurance until the insurance company is able to mail your official insurance card, which will be sometime after census day.

If you need to add dependents or extend dependent coverage on your policy, you
will need to contact stuhealthinsurance@utdallas.edu to request that your coverage be updated directly with the insurance
company. Dependent enrollment cannot be processed until the student’s enrollment
has been updated to reflect the current semester’s coverage. To add or extend
dependent coverage, please complete the International Dependent Enrollment Form
at utdallas.myahpcare.com.

Medical Policy Cost and Coverage Dates

2014-2015 Academic Year

Student Health Insurance Coverage

Period name

Coverage dates

Student

Spouse

All children

Student, Spouse & All Children

Fall 2014

8/1/14-12/31/14

$779*

$2,207

$1,213

$4,199

Spring 2015

1/1/15-5/31/15

$769*

$2,179

$1,197

$4,145

Summer 2015

6/1/15-7/31/15

$311*

$880

$484

$1,675

*Only the student premium will be charged to your student account. You will pay for coverage for dependents directly through Academic HealthPlans if you choose to have them covered. Please note that your coverage must be activated before you will be able to enroll dependents in the insurance plan.

Dental Policy Cost and Coverage Dates

2014-2015 Academic Year

Dental Coverage

Period name

Coverage dates

Student

Spouse

All children

Student, Spouse & All Children

Fall 2014

8/1/14-12/31/14

$101

$101

N/A

N/A

Spring 2015

1/1/15-5/31/15

$100

$100

N/A

N/A

Summer 2015

6/1/15-7/31/15

$40

$40

N/A

N/A

Repatriation and Evacuation

In the event of the insured's death, repatriation benefits will be paid for preparing and transporting the deceased to his/her home country. Evacuation benefits will be paid if the insured person is hospitalized for at least five consecutive days and recommended and approved by the attending physician for the evacuation of the insured to his/her home country.

Repatriation and medical evacuation coverage is included in the UT Dallas Student Health Insurance Plan. Students who are approved for SHI fee waivers with alternative insurance that do not include repatriation and medical evacuation coverage will be charged each semester at the student rate below. Students who wish to add spouses and/or dependents to that coverage can do so through the Student Health Center or directly with Blue Cross Blue Shield.

Exclusions and Limitations

No more than one surgical procedure will be covered when multiple procedures
are performed through the same incision or in immediate succession

Outpatient physical therapy except for a condition that required surgery or
a hospital confinement

Also, allergy medicines are covered and included in the $1,000 maximum under
prescription drugs. Benefits for treatment of sexually transmitted diseases are
covered up to $500 maximum per policy year, etc.